1073525010 NPI number — LUAN M BARGMAN PA

Table of content: LUAN M BARGMAN PA (NPI 1073525010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073525010 NPI number — LUAN M BARGMAN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BARGMAN
Provider First Name:
LUAN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MONTAG
Provider Other First Name:
LUAN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073525010
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
621 S ILLINOIS AVE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
MASON CITY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50401-5489
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-494-3041
Provider Business Mailing Address Fax Number:
641-494-3059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 4TH ST SW
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
MASON CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50401-2857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-428-6020
Provider Business Practice Location Address Fax Number:
641-428-7803
Provider Enumeration Date:
08/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  001296 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 23719 . This is a "WELLMARK" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".